13884-N-Brotons
Dietary advice in clinical practice: the views of general
practitioners in Europe1–4
Carlos Brotons, Ramon Ciurana, Rosa Piñeiro, Pilar Kloppe, Maciek Godycki-Cwirko, and Mario R Sammut on behalf
of EUROPREV
ABSTRACT
Background: General practitioners (GPs) can promote good
nutrition to patients and advise them about desirable dietary
practices for specific conditions.
Objective: The objective was to assess GPs’ knowledge and attitudes in implementing preventive and health promotion activities
and to describe tools used by European GPs in advising patients
about dietary practices.
Design: A postal survey was mailed to 1976 GPs from 10 GP
national colleges to obtain information about beliefs and attitudes in prevention and health promotion, and an e-mail survey
was sent to 15 GPs representing national colleges to obtain information about dietary guidelines.
Results: In the postal survey, 45% of GPs reported estimating
body mass in clinical practice, and 60% reported advising overweight patients to lose weight. Fifty-eight percent answered that
they felt minimally effective or ineffective in helping patients
achieve or maintain normal weight.
In the e-mail survey, only 4 colleges out of 15 reported that they
had published their own dietary tools, although 10 out of 15
answered that GPs use some nutritional/dietary recommendations in the office when seeing patients. Eleven out of 15
answered that both the nurse and the GP advise patients about
dietary practices, with 4 answering that GPs were the only ones
who advise patients. Only 5 delegates answered that they can
refer their patients to trained nutrition specialists.
Conclusions: GPs think that obesity is not easy to handle in
practice. Most GPs have dietary tools in the office and think that
nurses play an important role in advising patients.
Am J Clin
Nutr 2003;77(suppl):000S–000S.
KEY WORDS
Europe
Dietary tools, obesity, general practitioners,
INTRODUCTION
The European Network for Prevention and Health Promotion
in Family Medicine and General Practice (EUROPREV) is a network of European national colleges of general practice/family
medicine (presently representing 28 countries). It was established
in 1997 and is affiliated with the European Society of General
Practice/Family Medicine (World Organisation of Family Doctors—Europe), with the general aim of promoting evidence-based
prevention in general practice. Two of the specific objectives are
to define the role of the primary care doctor in health promotion
and prevention, and to promote and encourage multicenter research
and educational programs in prevention and health promotion
throughout Europe. Disease prevention and health promotion are
important tasks in the daily practice of all general practitioners
(GPs). A recent suggested definition of general practice (1, page
4) emphasizes the role of GPs in prevention, stating that “the general practitioner engages with autonomous individuals across the
fields of prevention, diagnosis, cure, care and palliation, using
and integrating the sciences of biomedicine, Medical Psychology,
and Medical Sociology.” Two-thirds of the population visit their
GP one or more times each year, and 90% visit at least once every
5 y (2). Therefore, GPs are in an excellent position to administer
age- and sex-specific preventive and health promotion packages
opportunistically—that is, when patients visit them for any reason. However, differences in the structure and organization of
practice in European countries are associated with a wide variation in the degree of involvement of GPs in preventive activities
(3). GPs also have a good potential to foster healthy behaviors.
Particularly, GPs can promote the benefits of good nutrition to
patients, advise them about desirable dietary practices for specific
conditions, and refer them to a trained nutrition specialist for
more detailed dietary counseling.
The objective of this study undertaken by EUROPREV was,
first, to assess the knowledge and attitudes of European GPs in
implementing preventive and health promotion activities in primary care as part of another project, particularly in advising
overweight and sedentary patients, and second, to describe the
tools used by GPs in advising patients about dietary practices.
SUBJECTS AND METHODS
Two surveys were carried out to achieve the objectives of
the study.
The first survey was carried out by mail from June to December 2000, using a prepaid addressed envelope. A pretested questionnaire was developed that included the following parts: (1)
1
From the Sardenya Primary Care Center, Barcelona, Spain (CB); La
Mina Primary Care Center, Sant Adrià del Besós, Spain (RC); Cangas Primary Care Center, Pontevedra, Spain (RP); Las Calesas Primary Care Center,
Madrid (PK); the Medical University of Lodz, Lodz, Poland (MG-C); and the
Department of Family Medicine, University of Malta, Malta (MRS).
2
Presented at the Third Heelsum International Workshop, held in Heelsum, the Netherlands, December 10–12, 2001.
3
Supported by a grant from the Programme of Prevention and Health Promotion of the Spanish Society of Family and Community Medicine.
4
Reprints not available. Address correspondence to Carlos Brotons, Sardenya Primary Care Center, C/Sardenya 466, 08025 Barcelona, Spain. E-mail:
cbrotons@eapsardenya.net.
Am J Clin Nutr 2003;77(suppl):1S–###S. Printed in USA. © 2003 American Society for Clinical Nutrition
1
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BROTONS ET AL
TABLE 1
Professional characteristics of general practitioners who participated in
the EUROPREV survey (n = 1976)
Area of practice
Urban area
Rural area
Both
Other
Site of practice
Primary health center
Solo practice
Hospital
Other
Center containing practice
Public center
Private center
Other
Postgraduate teaching activities
Yes
No
1070 (54.14)
379 (19.18)
488 (24.70)
39 (1.98)
934 (47.26)
497 (25.16)
50 (2.53)
495 (25.05)
1100 (56.67)
567 (28.70)
309 (15.64)
952 (48.17)
1024 (51.83)
1
n; % in parentheses. EUROPREV, European Network for Prevention
and Health Promotion in Family Medicine and General Practice.
demographic and professional data (10 questions); (2) 2 clinical
scenarios with a list of different preventive and health promotion
activities and 2 different columns for responses—beliefs and attitudes in practice (34 questions); (3) items related to barriers to
implementing preventive activities (6 questions); and (4) items
concerning personal health behavior (21 for GP males and 25 for
GP females). The questionnaire was translated and adapted from
English into the different national languages, being piloted by
10 GPs in each country. A random sample of GPs was selected from
databases that listed GPs from national colleges of each country.
With an estimated true proportion of 0.5 (the most conservative estimate), the maximum acceptable difference of 0.05, and
an alpha error of 0.05, the required sample size was calculated
per country according to the number of GPs affiliated with each
college. Assuming a minimum rate of participation of 50%, sample size was increased to compensate for anticipated loss. This was
done by multiplying the sample size by the quantity 1/(1 d),
where d is the anticipated loss. In some countries, such as Malta,
the questionnaire was sent to all the physicians, because of the
reduced number of GPs listed.
The second survey was done from June to September 2001. A
short questionnaire of 5 questions was sent out to 28 EUROPREV
delegates by e-mail, with the objective of obtaining information
about nutritional/dietary tools recommended by national colleges,
about advising and using special written dietary recommendations in practice, and about referring patients to specialists.
All collected questionnaires were sent back to the coordinating and data management center at the EUROPREV secretariat,
ensuring a centralized data entry and analysis by one research
technician specifically employed for this project. Statistical
methods were limited to the computation of means and standard
deviations for continuous variables, percentages for categorical
variables, and comparisons for categorical variables using chisquare at the 0.05 level of significance. All the analyses were
done using the Stata program (version 5.0; Stata Corporation,
College Station, TX).
RESULTS
Ten European countries participated in the postal survey
(Croatia, Estonia, Georgia, Ireland, Malta, Poland, Slovakia,
Slovenia, Spain, and Sweden), giving a total of 1976 GPs. Mean
age was 44 y (SD 9.5, range 23–84), and 61% were female. The
professional characteristics of GPs are shown in Table 1. The
2 clinical scenarios are illustrated in Figure 1. The results of the
questions related to the estimation of body mass index (BMI),
the advice to lose weight and to obtain physical exercise, and the
measurement of serum cholesterol, asking, first, if GPs believe
it should be done, and, second, if GPs do it in practice are
shown in Table 2. Fifty-six percent of GPs answered that the
First clinical scenario: A 52-year-old man visits you for the first time because of a trivial cough. He has not had previous checkups or tests. He has
no personal or family history of any major disease, and he does not have known risk factors.
Second clinical scenario: A 57-year-old woman visits you for the first time because of a trivial dermatological problem. She has not had previous
checkups or tests. She has no personal or family history of any major disease, and she does not have known risk factors.
Based on the scientific evidence and
current recommendations, should this
activity be done? (Circle the answer that
you consider appropriate.)
Do you usually carry out this activity (or do you refer
to the corresponding specialist) in patients with the
described patient’s characteristics? (Circle the answer
that you consider appropriate.)
Activity
Yes = 1
No = 2
I don’t know = 3
Yes = 1
No = 2
Measure serum total cholesterol level
Advise smokers to quit smoking
Advise heavy drinkers to reduce alcohol consumption
Estimate BMI
Advise overweight patients to lose weight
Advise sedentary patients to perform regular physical exercise
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
2
2
2
2
2
2
FIGURE 1. Two clinical scenarios with a list of different preventive and health promotion activities and two columns for responses, one for
responses about beliefs and attitudes and the other for responses about practice.
DIETARY ADVICE IN CLINICAL PRACTICE
TABLE 2
Responses to the first and second clinical scenarios
Should it
be done?
Do I do it?
% responding “yes”
First clinical scenario
Estimate BMI
Advise overweight patients to lose weight
Advise sedentary patients to perform
regular physical exercise
Advise smokers to quit smoking
Advise heavy drinkers to reduce alcohol
consumption
Measure serum total cholesterol level
Second clinical scenario
Estimate BMI
Advise overweight patients to lose weight
Advise sedentary patients to perform
regular physical exercise
Advise smokers to quit smoking
Advise heavy drinkers to reduce alcohol
consumption
Measure total serum cholesterol level
62.74
85.52
83.50
46.66
61.73
56.66
96.56
87.10
70.80
63.21
61.59
57.24
63.72
84.21
80.01
41.81
58.76
53.75
85.88
81.53
60.07
55.87
63.26
55.52
implementation of prevention and health promotion activities is
difficult, 58% answered that they felt minimally effective or
ineffective in helping patients achieve or maintain normal
weight, and 53% answered that they felt minimally effective or
ineffective in helping patients practice regular physical exercise.
No differences were found between obese GPs (BMI > 30 kg/m2)
and nonobese GPs in advising overweight patients to reduce
weight and in their perception of effectiveness in helping patients
to achieve or maintain normal weight.
Fifteen EUROPREV delegates representing the GP national
colleges of Austria, Croatia, Georgia, Greece, Ireland, Malta, the
Netherlands, Poland, Portugal, Russia, Slovakia, Slovenia, Spain,
Switzerland, and the United Kingdom answered the e-mail
questionnaire.
Four colleges recommend their own dietary or nutritional
tools, although none of them were specific nutrition/dietary
guidelines; instead, they were integrated into other condition
guidelines such as hypertension, diabetes, and dyslipidemia.
Nevertheless, 10 delegates out of 15 answered that GPs use some
nutritional/dietary recommendations in the office when seeing
patients, and when asked who does this, 4 answered the GPs
themselves, and 11 answered both the nurse and the GP. Ten delegates out of 15 answered that they provide their patients with
special written dietary recommendations (eg, a diet that contains1500 kcal per day, or 2000 kcal per day). Only 5 delegates
answered that they can refer their patients to trained nutrition
specialists, with the major reason why they cannot do this being
the absence of reimbursement.
DISCUSSION
European networks such as EUROPREV permit the running of
specific research projects, such as the survey that we carried out of
nearly 2000 GPs from 10 European countries. However, it is difficult to compare our results with the ones obtained in other surveys
because different methods were used. The results of the 2 clinical
scenarios show that GPs believe they should calculate BMI in
3S
60% of patients, but in practice they do it in only 45% of patients.
Asked about advising overweight patients to lose weight, GPs
believe this activity should be done in 85% of patients, but again,
this percentage falls in practice to 60% of patients. This also
happens with the other 2 activities advised (increasing physical
exercise and quitting smoking), and it is not so clear with the measurement of total cholesterol, perhaps reflecting the fact that GPs
would rather order tests than give verbal advice.
Other studies that evaluated preventive services in routine
general practice have shown similar results to ours, and when
primary care physicians were asked if weight was checked, 42%
answered that they did this activity in practice (4). These results
illustrate that some GPs may think that measuring weight,
height, and BMI is a waste of time, because overweight and
obese patients may be the worst group of patients on whom to
test the success of dietary advice. Also, resources in primary care
are limited, and if a GP or a nurse spends 5 min of a 10-min consultation on dietary advice, this will result in 5 min less to spend
on the rest of the consultation.
We observed that more than half of the GPs were skeptical
about helping patients achieve or maintain normal weight. Other
surveys have shown similar results, with, for instance, in Canada
(5) 48% of primary care physicians believing that dietary change
has little effect and more than half stating that interventions for
obesity have limited effect (after adequate training and support).
In the United Kingdom, another study (6) showed that 50% of
GPs felt potentially effective (after adequate training and support) in helping patients avoid excess calories, although only 20%
felt currently effective.
Our network of GPs’ colleges also has the possibility to obtain
and share useful information from national colleges of GPs
enrolled in EUROPREV and compare not only organizational
health services but also guides and tools used for prevention and
health promotion in clinical practice. Although we studied European GPs, the results do not represent all countries of Europe,
and therefore we would welcome information from additional
national colleges.
It is clear from our results that most of the national colleges do
not have their own dietary/nutritional tools; however, they usually
use recommendations developed by other institutions and provide
the patients with specially written information. This fact is important because previous studies have shown that, in 16% of presenting episodes of illness, nutritional guidelines must be considered as an essential part of treatment (7). Also, our results
indicate that nurses play an important role in advising patients
about desirable dietary practices. However, when GPs and nurses
do not have the time, knowledge, or skills to advise their patients,
it is not easy to refer them to a professional qualified in nutrition
for more detailed dietary counseling because referral to dietitians
is usually not covered by medical insurance. Surveys such as this
are in large part based on self-reporting by GPs and reflect what
GPs think they do or should do. More objective evidence (eg,
chart audits) is needed to see what GPs actually do; for this reason, it is crucial that GPs systematically record most relevant preventive and health promotion activities.
There were no conflicts of interest.
The EUROPREV network includes the following individuals and institutions
(which participated in this study): Celia Björkelund (The Swedish Association of
General Practice), Carlos Brotons, Ramon Ciurana, Pilar Kloppe, Rosa Piñeiro
(Spanish Society of Family and Community Medicine), Eva Jurgova (Slovak
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BROTONS ET AL
Society of General Practice), Mateja Bulc (Slovenian Medical Association),
Artur Mierzecki, Maciek Godycki-Cwirko (The College of Family Physicians
in Poland), Liivia Pullerits (Estonian Family Doctors Association), Jasna
Vuchak (Croatian Association of Family Physicians), Mario R Sammut
(Malta College of Family Doctors), Mary Sheehan (Irish College of General
Practitioners), Revaz Tataradze (Georgia Association of General Practitioners
and Family Physicians), Ton Drenthen (Dutch College of General Practioners), Godfrey Fowler (Royal College of General Practitioners), Elena V Frolova (St-Petersburg Medical Academy of Postgraduate Study), Christos Lionis,
Lefteris A Thireos (Greek Association of General Practitioners), Carlos Martins (Portuguese Association of General Practitioners), Ingrid Pichler (Austrian Society of General Practice and Family Medicine), and Maxime Mancini
(Swiss Association of General Practitioners).
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